Sault Tribe Housing Authority Improvement Program (906)495-1450 or (800)794-4072 o Home Rehab

Application Instruction Sheet

o Complete Application ./ Application must be completely filled out and signed to be eligible for program o Tribal card ./ For all household members o Social Security Card & Drivers License ./ For all household members o Income Verification for last 12 months ./ Most current year taxes (Federal 1040 & W-2 's) ./ Check Stubs for past month ./ Child Support Order & Custody Order for Children ./ Yearly SSI Benefit Letter o Proof of Ownership - in ApplicantlTribal Member's name ./ Deed, Mortgage Agreement, Quit claim ./ MUST OWNLAND - NO Land Contracts & No Trailers on a Rented Lot o Proof of current Mortgage payment ./ Monthly Statement, Statement from lender o Proof of current Home Owner Insurance ./ Copy ofHome Owner Insurance Policy o Proof of current Property Tax ./ Statementfrom local Treasure Office that taxes are paid in full o Verification of Housing Condition ./ Statement from Home Owner in regards to condition ofunit ./ Pictures ofHome (Ifquestions, please contact the Home Ownership Department)

YOUR APPLICATION WILL NOTBE PROCESSED IFALL THE ABOVE INFORMATION IS NOT COMPLETED & TURNED IN

WARNING! TITLE 18, SECTION 1001 OF THE UNITED STATES CODE, STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES. Penalties for committing fraud, ifyour application or updated information contains false or incomplete information, you may be: • Required to repay all monies expended on your home by the Sault Ste. Marie Tribe o/Chippewa Indians. • Fined up to $10,000.00. • Imprisoned/or up to 5 years; and/or • Prohibited/rom receiving/uture assistance.

Please send completed applications and copies of supporting documents to: Sault Tribe Housing Authority Home Improvement Program - Jamie Harvey 154 Parkside Drive Kincheloe, MI 49788 Rec'dBy: SAULT TRIBE HOME IMPROVEMENT ---­ AUTHORIZATION TO Date: RELEASE INFORMATION -----­ Time: ------

TO WHOM THIS MAY CONCERN:

I/we hereby authorize you to release to the Housing Authority for verification purposes, any and all information concerning the following:

1. Employment history to date, titles, income, hours worked, etc. 2. Banking, savings, and 11M accounts of record 3. General assistance income, and 4. Any other information requested as deemed necessary to verify my/out application.

This information is for the CONFIDENTIAL use by the Housing Authority in evaluating my/our application for Housing Improvement Program (HIP) financial assistance.

A photographic or carbon copy of this authorization (being a photographic or carbon copy of the signature(s) of the undersigned) may be deemed to be equivalent of the original and may be used as a duplicate original. This form MUST be notarized.

Applicant's Signature (Full name) Date

Parent/Guardian Signature (If required) Date

Full Name of Applicant (print) Social Security Number

Address of Applicant Telephone Number

Subscribed and sworn before me this ____day of ______

Notary Public PRIVACY ACT NOTICE

Pursuant to the Privacy Act of 1974, as amended, as codified in 5 U.S.C. 522a(e)(3), individuals furnishing information on this form are hereby advised as follows:

1. The authority for solicitation of the information is 5 U.S.C. 522a(e) and the Bureau of Indian Affairs “Housing Improvement Program” regulations, Title 25 Code of Federal Regulations, Chapter 1, Part 256.4 Information Collection.

2. The information collected requirements contained in Part 256.13 have been approved by the Office of Management and Budget under 44 U.S.C. 3507 et. Seq. and assigned clearance number 1076-0084. The information will be used to determine eligibility to participate in the Housing Improvement Program (HIP).

3. The information contained in this application may be made available to authorized sources upon request.

4. Failure on the part of the applicant to provide the requested information may preclude this applicant from eligibility in obtaining housing assistance under the Housing Improvement Program.

5. The disclosure of your social security number is optional. However, failure to disclose the social security numbers for those and all other permanent household members may result in a delay and/or denial of this grant.

I have read the above statement and agree to provide the required information and authorize the use of such information to the extent of the uses specified in the notice.

______Applicant’s Signature Date

______Spouse’s Signature (Include Maiden Name) Date

Year Round Residency Certification

Please fill in the following statement to qualify your home for service.

Date you purchased your home / / Month Day Year

I/we, ______, swear that this is my only real property. I/we must live year- round at this property to receive Home Improvement Services through the Sault Ste. Marie Tribe of Chippewa

Indians, Home Improvement Program. If it is found that this property is not my permanent year round residence or that I/we own more than one home, the total cost of these services is to be reimbursed immediately to the Sault Ste.

Marie Tribe of Chippewa Indians.

My year-round permanent residence is:

Phone Number:

Signature Date

Spouse Signature (If applicable) Date

Witness Date

Asset Verification Form

Sault Tribe Housing Authority ~ Home Improvement Programs

Applicant Co-Applicant You must answer all questions, please use the back to explain, if necessary. Yes No Yes No

Do you or any other household member own a home or other real estate? (Example: rental unit, vacant property, etc.)

If Yes, what is the market value? $ You must provide Verification. $

Do You or any other household member have a

401K or an IRA Savings account?

If Yes what is the market value? $ $ You must provide verification.

Do You or any other household member have a

Checking or Saving s Account?

If Yes what is the market value? $ $ You must provide verification.

Have you or any member of your household sold or given away real property or other assets in the past two (2) years?

If yes, what was the market value? $ You must provide Verification. $

I/We certify that the information given above to the Sault Tribe Housing Authority on family assets is accurate and complete to the best of my knowledge and belief. I/We understand that false statements are grounds for termination of housing assistance and possible repayment of grant funds.

Signature of Head of Household Date Signature of Spouse Date

Signature of Other Adult Date Signature of Other Adult Date

BIA Form 6407 OMB Control No. 1076-0184 ISSUED 11/10/2015 EXPIRATION DATE: 10/31/2018

UNITED STATES DEPARTMENT OF THE INTERIOR BUREAU OF INDIAN AFFAIRS HOUSING ASSISTANCE APPLICATION

• All questions in this application must be answered. The requested information is self-explanatory. • This application is subject to the Privacy Act of 1974, Pub. L. 93-579

A. APPLICANT INFORMATION______

1. Name:______Last First MI Maiden Name (if any)

2. Current Address: ______Street Address P.O. Box # (if any) ______City State Zip Code

3. Telephone Number: (____)______

4. Date of Birth: ______5. Social Security Number: ______

6. Tribe: ______Roll Number: ______

Reservation/Rancheria: ______

7. Marital Status: ____Married ____Singled ____Widowed ____Other

If you checked “Other”, please explain. ______

8. Are you Homeless? ____ No ____ Yes 9. Are you or spouse a Veteran? ____ No ____ Yes

Information About Spouse: ______

10. Name:______Last First MI Maiden Name (if any)

11. Date of Birth: ______12. Social Security Number: ______

13. Tribe: ______Roll Number: ______

B. FAMILY INFORMATION______

List all other persons living in household on a permanent basis. Start with the oldest and provide Name, Date of Birth, Social Security Number, Relationship to Applicant, and Tribe/Roll Number . Name Date of Birth Social Security # Relationship to Applicant Tribe/Roll Number

If you need more space, use a blank sheet of paper.

Date of this application:______1

BIA Form 6407 OMB Control No. 1076-0184 ISSUED 11/10/2015 EXPIRATION DATE: 10/31/2018

C. INCOME INFORMATION______

14. Earned Income: Start with applicant, then list all permanent family members, including all who are listed under Parts A and B and have earned income. Provide signed copy of SF-1040 (income tax return), W-2 forms, wage stubs, etc. for verification. Name Annual Earned Income Source of Income

Total annual earned income: $ ______

15. Unearned Income: Start with applicant, then list all permanent family members, including all who are listed under Parts A and B and have unearned income such as social security, retirement, disability and unemployment benefits, child support and alimony, royalties, per capita payments, interest, etc. Provide check stubs, statements, individual Indian Money (IIM) ledgers, etc. for verification.

Name Annual Unearned Income Source of Income

Total annual unearned income: $ ______

16. TOTAL COMBINED ANNUAL HOUSEHOLD INCOME (earned + unearned): $ ______

D. HOUSING INFORMATION______

17. Location of the to be repaired, renovated or constructed. (Give address and detailed directions to this house). **DRAW MAP ON BACK OF THIS PAGE**

18. Provide a brief description of the problems you are experiencing with your house or the type of housing assistance for which you are applying.

19. If repair assistance is needed, do you own _____ or rent _____ this house? If renting, is the owner Indian? ____No ____ Yes If yes, provide name of owner(s): 20. Are you living in Overcrowded Conditions? ____ No ____ Yes 21. Is the condition of the home in a dilapidated state? ____ No ____ Yes

Date of this application:______2

BIA Form 6407 OMB Control No. 1076-0184 ISSUED 11/10/2015 EXPIRATION DATE: 10/31/2018

HOUSING INFORMATION, continued. 22. Is available? ____No ____Yes If yes, provide name of electric company: ______. 23. Type of Sewer system: ___ City Sewer ___ Septic Tank ___ Chemical ___ Outhouse Water Source: ____ City Water ____ Private Well ____ Community Water Tank ____ Other (Please describe): 24. No. of ____. 25. House Size: _____ (Square Feet) [ LENGTH _____ ft/in] [WIDTH _____ ft/in] 26. facilities in existing house: Facility Yes No Flush toilet Bathtub Sink/lavatory

E. LAND INFORMATION______

27. Do you own the land on which you wish to renovate or build this home? _____ Yes _____ No If no, can you provide proof that you can obtain land? ____ Yes _____ No Provide the name of the owner(s): 28. What is the current ___ Fee ___ Tribal Fee ___ Native/Restricted status of the land? ___ Individual trust land ___ Tribal trust land ___ Public Domain ___ Individually restricted ___ Tribally restricted ___ Other: 29. If you do not own the land, do you have: _____ Leasehold interest? ____ Use permit? ______Indefinite assignment or joint ownership? If so, please explain:

F. GENERAL INFORMATION______

Yes No 30. Have you or anyone in your household ever received Housing Improvement Program assistance? If yes, give amount received $______; the year it was received: 19__ __; and the location of the house: 31. Do you own any other house not occupied by your family? If yes, state where the house is located: ______and who occupies it: ______. 32. Do you live in a house built with Housing and Urban Development (HUD) funds? 33. Is the HUD project still under operation of an Indian Housing Authority? 34. Are you seeking Down Payment Assistance? If yes, have you applied with USDA Rural Development or other lending institution? Please provide a copy of the credit letter. 35. If you are requesting assistance for a new housing unit, have you applied for assistance from: • Indian Housing Authority? If yes, provide date of application:______• Tribal Credit Program? If yes, provide date of application:______• Other? From who:______If yes, provide date of application:______36. Does anyone in your family, who is a permanent resident listed under Parts A and B of this application, have a severe health problem, handicap or permanent disability? If yes, provide name of family member ______and brief description of condition. (Your servicing housing office will advise you if you must provide a statement of condition from one source, which may include a physician’s certification, Social Security or Veterans Affairs determination, or similar determination).

Date of this application:______3

BIA Form 6407 OMB Control No. 1076-0184 ISSUED 11/10/2015 EXPIRATION DATE: 10/31/2018

G. APPLICANT CERTIFICATION ______(Read this certification carefully before you sign and date your application. Sign in ink).

I certify that all the answers given are true, complete and correct to the best of my knowledge and belief, and they are made in good faith. This certification is made with the knowledge that the information will be used to determine eligibility to receive financial assistance, and that false or misleading statements may constitute a violation of 18 U.S.C. 1001.

This application contains material covered by the Privacy Act. No record will be communicated to anyone or any agency unless requested in writing, by the applicant, or unless an officer or employee of the housing program or other Federal agency requires it in the performance of their duties.

Applicant’s Signature: ______Date: ______

Spouse’s Signature (if appropriate) ______Date: ______

PRIVACY ACT STATEMENT

25 CFR 265 and 25 U.S.C. 13 authorize the collection of this information. This information is covered by the system of record notice “Indian Housing Improvement Program, Interior, BIA-10.” The primary use of this information is to determine eligibility for assistance under the Housing Improvement Program. The records contained therein may only be disclosed in accordance with the routine uses and may not otherwise be disclosed by any means of communication to any person, or to another agency, except pursuant to a written request by, or with prior written consent of the individual to whom the record pertains. If the BIA uses the information furnished on this form for purposes other than those indicated above, it may provide you with an additional statement reflecting those purposes. Executive Order 9397 authorizes the collection of your Social Security number. Furnishing the information is voluntary but failure to do so may result in disapproval of your application.

PAPERWORK REDUCTION ACT STATEMENT

This information is being collected to select eligible families or individuals to participate in the Housing Improvement Program. Response to this request is required to obtain a benefit in accordance with 25 CFR 256. You are not required to respond to this collection of information unless it displays a currently valid OMB control number. This information will be used to determine the eligibility and the ranking of the applicant. Public reporting burden for this form is estimated to average 1 hour per response, including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of this form to Information Collection Clearance Officer – Indian Affairs, 1849 C Street, NW, MS-4141, Washington, DC 20240.

Date of this application:______4